FUNDAMENTALS 👀

• Client's Chart

  • Contains systematic documentation of an individual patient’s important clinical data and medical history over time
  • Includes vitals, medications, treatment plans, allergies, immunizations, test results, patient demographics, diagnoses, progress notes, and reports
• Without patient charts, even highly experienced doctors can misdiagnose patients or set up treatment plans that yield no results
• Patient medical charts display a patient's key medical information so practitioners can make more accurate diagnoses and develop treatment plans with better outcomes
• Learning Objectives:
• The comprehensive patient data in client's charts provides all the information needed to make proper diagnoses, prescribe appropriate medications, order appropriate bloodwork, and set up robust treatment plans
• Patient demographics data includes patient name, address, phone numbers, email address, sex, age, birthday, race, occupation, employer information, and emergency contact details
• Consent and Authorization Forms in a client's chart are signed statements from the patient or guardian approving the course of treatment
• Financial information in a client's chart includes assignment of benefits, insurance details, responsible party information, and patient's relationship with the insured
• Key Elements of a Client's Medical Chart

  • Patient demographics
  • Financial Information
  • Consent and Authorization Forms
  • Diagnosis and chances of recovery
  • Release of information
• The notice required by the DPA gives patients the right to be informed about their privacy rights regarding their protected health information
• Release of information in a client's chart requires a valid authorization to release protected health information, identity verification, description of information to be used or disclosed, and details of the authorized person or organization
• Doctor’s Orders

  • Physician’s orders for the patient to receive testing, procedures, or surgery including directions to other treatment team members
  • Prescriptions for medications and medical supplies or equipment for the patient’s home use
  • Findings opinions from consulting physicians
• Personal information must be safeguarded and protected against any accidental or unlawful destruction, alteration, disclosure, and other unlawful processing
• Healthcare facilities have a responsibility to their patients by law to keep their personal health information private and secure. Disclosures made regarding a patient’s protected health information without their authorization are considered a violation of the DPA
• Data Privacy Act 2012 or RA 10173 is a comprehensive and strict privacy legislation to protect the fundamental human right of privacy and communication while ensuring free flow of information to promote innovation and growth
• Nursing Records


  • Vital indicators including blood pressure, temperature, pulse, respiration, intake, output, etc of the patient are recorded
  • Nurse’s notes include documentation separate from the physician including Assessment, Nursing Diagnosis, Planning, Intervention, & Evaluation
• This notice, as required by the DPA, gives patients the right to be informed about their privacy rights as it relates to their protected health information (PHI)
• Medical (Treatment) History

  • Chief complaints
  • History of illness
  • Vital signs
  • Physical examination
  • Surgical history
  • Obstetric history
  • Medical allergies
  • Family history
  • Immunization history
  • Habits such as exercise, diet, alcohol intake, smoking, and drug use/abuse
  • Developmental history
• Observations in Progress Notes

  • Physical and mental condition of the patient
  • Sudden changes in the patient’s condition
  • Vital signs at certain intervals
  • Food intake
  • Bladder and bowel functions
• Medication List


  • Prescribed medication including dose, method of intake, and schedule
• Healthcare professionals must ensure that the methods of their data collection and processing regarding health information are properly handled with confidentiality and the data subjects must be well aware of the process, including a breach of security, should there be any
• Reports on Consultations

  • Documentation provided by experts the doctor contacted to evaluate the patient
• Operative and Anesthesiology Report


  • Surgeon’s written account of the process, including the preoperative and postoperative diagnoses, the surgical procedure specifics, the patient’s response, and any complications
  • Information from the attending anesthesiologist or anesthetist providing a thorough account of anesthesia during surgery
• Additional or other Reports


  • Maintain a record of treatments or procedures given to patients, such as blood transfusion, chemotherapy, respiratory therapy, or physical therapy
• Diagnostic Procedures and Lab Results


  • Findings of every diagnostic test and laboratory procedure that the patient underwent
  • Outcomes of samples taken from the patient documented in the pathology report
  • Record of findings from radiology testing, Ultrasound, ECG
• Progress Notes


  • New information and changes during patient treatment documented by the doctor
  • Documentation outlining the patient’s condition, outcomes of the doctor’s assessment, a summary of the test results, the treatment plan, and any necessary data updates
• Discharge Summary


  • Summary of the patient’s hospital care, including admission date, diagnosis, treatment course, patient responses, test outcomes, final diagnosis, follow-up plans, and discharge date
• Nurse's Responsibility: Ensure t
• Nurse's Responsibility

  • Ensure that records are accurate and complete to effectively manage the client and allow for good communication between the nurse and other healthcare members
  • Keeping good nursing records allows for identifying problems that have arisen and the action taken to rectify them
  • Part of the nursing care given to patients
  • Without clear and accurate nursing records for each patient, endorsement to the next shift of nurses will be incomplete
  • The quality of record-keeping can be a good (or bad) reflection of the standard of care given to patients
  • Careful, neat, and accurate patient records are the hallmarks of a caring and responsible nurse, but poorly written records can lead to doubts about the quality of a nurse's work
  • Nursing records are proof that you have fulfilled your duty of care to the patient
  • Poor record-keeping can mean negligence even if provided the correct care - and this may cause you to lose your right to practice
• Keeping Good Nursing Record

  • All documentation must be legible and written in ink or typewritten
  • Documentation should be completed within 48 hours after the patient is discharged
  • A written History and Physical Examination should be completed upon consultation or within 24 hours after the patient is admitted for confinement
  • To ensure quality documentation, there should be a Medical Record Committee (MRC) which shall review and revise, if necessary, the medical record forms
  • Use of abbreviations in writing the diagnosis shall not be allowed, but the use of symbols with an explanatory legend by authorized personnel may be allowed with the approval of the hospital management
  • Short forms like laboratory and other result forms should be securely fastened to the records to prevent loss
• "If you didn't document it, you didn't do it."
• Discharge Summary


  A summary of the patient’s hospital care, including the date of admission, the diagnosis, the course of treatment and any responses from the patient, the outcomes of the tests, the final diagnosis, the follow-up plans, and the date of discharge